A nurse on a postpartum unit is caring for a group of clients. Which of the following clients is the nurse’s priority?
A client who is 2 days postpartum and whose fundus is 2 to 4 cm below the umbilicus.
A client who is 3 days postpartum and has not had a bowel movement since prior to admission.
A client who is 4 days postpartum and has lochia serosa.
A client who is 1 day postpartum and has not voided in 8 hr.
The Correct Answer is D
A client who is 1 day postpartum and has not voided in 8 hr. This client is at risk of urinary retention, bladder distension, and infection due to the effects of epidural anesthesia, perineal trauma, and fluid shifts after delivery. The nurse should assess the client’s bladder and catheterize if necessary.
Choice A is wrong because a client who is 2 days postpartum and whose fundus is 2 to 4 cm below the umbilicus is showing a normal finding.
The fundus should descend about 1 to 2 cm per day after delivery and be nonpalpable by day 10.
Choice B is wrong because a client who is 3 days postpartum and has not had a bowel movement since prior to admission is not uncommon.
Constipation is a common problem after delivery due to decreased peristalsis, dehydration, and fear of pain.
The nurse should encourage fluid intake, fiber intake, and early ambulation to promote bowel function.
Choice C is wrong because a client who is 4 days postpartum and has lochia serosa is also showing a normal finding.
Lochia serosa is the pinkish-brown discharge that occurs from day 4 to 10 after delivery.
It consists of old blood, serum, leukocytes, and tissue debris.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Use short phrases when talking to the client.
Some possible explanations for the other choices are:
Choice A is wrong because speaking in a louder than usual tone of voice during conversation can distort the sound and make it harder for the client to understand.
The nurse should speak in a normal tone and enunciate clearly.
Choice C is wrong because avoiding the use of hand gestures when talking to the client can limit nonverbal communication and reduce the client’s comprehension.
The nurse should use appropriate facial expressions
Correct Answer is A
Explanation
Encourage the client to help care for their surgical incision. This can help the client accept the body image change and promote healing.
Choice B is wrong because suggesting that the client decide about reconstruction as soon as possible can pressure the client and interfere with their coping process.
Choice C is wrong because postponing referrals to support services until the client requests them can delay the client’s emotional recovery and increase their isolation.
Choice D is wrong because avoiding talking to the client about the surgery can indicate that the nurse is uncomfortable with the topic and discourage the client from expressing their feelings.
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